Confronting the Imposter Within

Part of the Break Point Special Report
To read Are PHPs Still In Our Corner? – Click here
To read Don’t Hold It Against Me – Click here

Many physicians suffer from imposter syndrome – the belief that their success is based more on luck then skill and could disappear at any moment. Here’s how to tell if you have it, and what you can do to confront it.

“The beauty of the impostor syndrome is you vacillate between extreme egomania and a complete feeling of: ‘I’m a fraud! Oh God, they’re on to me! I’m a fraud!’ —Tina Fey, Actor, Comedian, Writer and Producer

Like Tina Fey, many so-called impostors have been front and center in literature and culture. These individuals, despite receiving objective evidence that they are successful and talented, live with a constant dread of failure. Sound familiar? Have you ever felt like you weren’t really as good as others thought you were?

On my first day of medical school, I was on the elevator going up to the opening session and the elevator got stuck. Of course, it was packed full of nervous new medical students and faculty, crowded together. I was up front by the doors and jolt, grind, halt, the elevator was stuck. I quickly surmised the situation at hand (like any good emergency nurse) and blurted out, “Oh great, I knew they would find me out, I just didn’t think it would be before I got there”. From somewhere, back in the crowded nervous elevator came a voice: ‘Oh, you have Impostor Syndrome, don’t worry, most of the kids here today have it and the rest are just too clueless to know they have it’.

Fast forward 25 years. I was chair of the American College of Emergency Physicians Scientific Assembly, the largest EM meeting in the world. I was up on the dais chatting with a speaker before introducing him for a lecture. This speaker was being proffered the ‘Speaker of the Year Award’ by the college, which is no small feat. Hundreds of faculty, countless lectures and evaluations had rightly anointed this doctor with this prestigious award. As I thanked and congratulated him on his award, he said, “I am just waiting for someone to realize that I am just an average lecturer.” “OMG!” I blurted out, “You have Impostor Syndrome!” We chatted briefly about it afterward, and it started me thinking. How many people have this? What is it really? Can I do anything to overcome it or help others?

What is Imposter Syndrome?
The term ‘Impostor Phenomenon’ was first described in 1978 in a psychotherapy journal [2]. The article noted a significant number of high-achieving women who believed they were not intelligent, and that they were “over-evaluated” by others. These subjects believed once they were “outed,” their success would vanish.

Often called the “domain of the over-achiever,” Impostor Syndrome refers to people who believe a part or all of their success is undeserved. Furthermore, people suffering from Impostor Syndrome tend to experience feelings of anxiety about their success and many of them work harder to compensate. Many people don’t actually know they have it until someone else describes it to them, then they say, “How did you know how I feel?” Despite being successful by most standards they feel as if their success was just a fluke or an external series of lucky events. They fear that they could not repeat the success and their life would be ruined if found out. In the end, fear and self-doubt interfere with their enjoying their success at all.

Is it common?
Yes. We conducted an informal survey of 71 residents and faculty members at two residency programs and found that 75% of respondents felt some of their success was not deserved, 70% reported experiencing feelings of anxiety about their success and 68% felt they work harder because they felt some of their success was not deserved. Academy Award winner Jodie Foster told 60 Minutes she feared she’d have to give her Oscar back after winning best actor for The Accused. “I thought it was a fluke,” she said in the interview. “[It was] the same way when I walked on the campus at Yale. I thought everybody would find out, and they’d take the Oscar back. They’d come to my house, knocking on the door, ‘Excuse me, we meant to give that to someone else. That was going to Meryl Streep.’” The American author and poet Maya Angelou said “I have written eleven books, but each time I think, ‘Uh oh, they’re going to find out now. I’ve run a game on everybody, and they’re going to find me out.’”

Who is at higher risk?
High achievers, women more than men and those who work in creative fields tend to be at higher risk to develop Impostor Syndrome. Valerie Young, author of The Secret Thoughts of Successful Women, says countless millions of high-achieving people don’t experience an inner sense of competence or success. “Despite often overwhelming evidence of their abilities, impostors dismiss them as merely a matter of luck, timing, outside help, charm – even computer error. Because people who have the impostor syndrome feel that they’ve somehow managed to slip through the system undetected, in their mind it’s just a matter of time before they’re found out.” Perceived fraudulence, which is often linked to Impostor Syndrome, has been found to be more common in individuals who are highly critical of themselves [3].

Gender
Gender does seem to play a role. Young found that men more often blame external factors in describing their failures while women cite internal factors.

“Despite the fact that I’ve been a corporate vice president, a president, a CEO, and have served on the boards of four Fortune 500 companies, I struggled for many years during my career before I no longer needed external validation to believe I was doing a great job,” said Joyce Roche, CEO of Girls Inc. “Just about every new accomplishment came with the stultifying doubt that I did not deserve the success and that sooner or later I would be discovered as an impostor.”

That said, our own survey didn’t bear this out – with men and women reporting impostor syndrome in similar amounts and degrees. Furthermore, 21% of males and 22% of females answered in the affirmative for the most severe cases (those who responded “often” or “all the time” on at least 2/3 of the impostor syndrome questions).

Why do we care?
Why does all this matter? High impostor feelings have been found to be significantly related to the presence of defensive pessimism and low self-esteem [4]. If left unchecked, impostor syndrome can lead to anxiety, burnout and depression (Wound Care Advisor, 2013). While it’s been noted that people with impostor syndrome tend to be intelligent, thoughtful and capable, feelings of self-doubt can breed issues related to self-confidence – particularly when the person experiencing impostor syndrome feels their success is unwarranted. Finally, addressing this issue can even have an impact on patient satisfaction. One study found students rated tenured professors higher if the professors rated themselves as more secure, goal-directed and self-assured [5].

Could it affect me?
This syndrome can impact us in our professional encounters in ways we do not understand or see. It may be present with some residents or attendings as they achieve a certain level of success and then start to falter. It be present itself when we struggle with self doubt during an interaction with a consultant. Or we may have a difficult time advocating for our patients in an appropriately assertive manner. It may manifest itself in a variety of unwanted behaviors that negatively impact both our ability to enjoy our work and ultimately could negatively impact the care we want to provide our patients.

What can I do about it?
There is power in knowledge. Knowing that others share the same feelings and thoughts is a huge relief and also a source of personal power. The concept, ‘I am not as special as I think I am, therefore, others feel and think the same things as I do’ can help release these feelings. Just knowing about it, reading about it and talking about it with others help identify the phenomenon in themselves and others. And that, in itself, may be enough to curb the corrosive effects of Impostor Syndrome. For a list of ideas on how to combat imposter syndrome, check out the sidebar.

2 Comments

I would guess, and this is JUST a guess, albeit educated, that “Imposter Syndrome” is more common in all caregivers of either gender than in the general population. It might explain why we are more susceptible to burnout.
My guess is based on forty years or so of observation of physicians including years of close communication with those experiencing various types of professional difficulties, and also published studies of the personality characteristics of physicians dating back at least to the 70s.
Many people are drawn to healing professions because they have experienced a care deprivation themselves during childhood, often as the result of having an ill parent or relative. These children themselves became caretakers at a quite early age. When it became time to choose a livelihood, it makes sense that some would say “I already know that I am good at that”. However, there is still an unmet need that follows these children into their careers. It is irrational, but there is at least in part a hope that by caring exceptionally well for others they themselves might finally experience the care they missed as children.
THis is one reason that physicians who are sued for malpractice feel so betrayed. “I did everything I could do for this patient. Why are they now blaming me?” Or worse, “you know, I did a lot for this patient but if I had only done EVERYTHING HUMANLY POSSIBLE then perhaps they would have had a better outcome.” In the worst case, this boils down to “I am an imposter and shouldn’t pretend to be a healer.” Plaintiff attorneys mine these insecurities for all that they are worth.
I think that Kerry and Michael’s findings are instructive and their advice is sound. I would go a bit further and say that if you have NEVER felt like an imposter at some point in your quest to become a healer, then you may be in the wrong profession. A little bit of self doubt makes us never stop learning to care more effectively. But if it begins to make us INeffectual caregivers, it is time to seek greater self knowledge and a source of support.

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